Models of Mental Health Integration for Rural Health Clinics
Rural Health Clinics: A General Overview
Transcript of Rural Health Clinics: A General Overview
Rural Health Clinics: A General Overview
Charles A. James, Jr. President and CEO
North American Healthcare Management Services
www.northamericanhms.com 888.968.0076
Overview
The following areas will be discussed:
What is an RHC?
RHC Reimbursement
Independent vs. Provider-Based RHCs
RHC Location Requirements
RHC Staffing Requirements
Provision of Services
Resources
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What is an RHC?
A Rural Health Clinic (RHC) is a clinic certified to receive special Medicare and Medicaid reimbursement.
The purpose of the RHC program is improving access to primary care in underserved rural areas.
The clinic must be staffed at least 50% of the time with a midlevel practitioner.
(Rural Assistance Center FAQ) www.northamericanhms.com 888.968.0076
Independent RHCs
Independent RHCs are generally private physician offices or hospital clinics whose parent is > 50 beds.
RHC encounters are paid using the current RHC cap.
Independent RHCs must file an annual cost report, which is due 5 months after the end of each fiscal year.
Failure to file timely cost reports can result in full refunds of RHC payments.
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Provider-Based RHCs
Provider-based RHCs (PBRHC) are those owned by, and fully integrated with, a parent entity such as a hospital, nursing facility, or home health agency.
PBRHCs owned by a hospital with 50 beds or less qualify for an un-capped RHC rate.
Claims are billed to the MAC which services the parent entity.
PBRHCs whose parent entity is greater than 50 beds have the same cap as independents.
PBRHCs rate is set under the parent entity’s cost report.
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Cost Based Reimbursement
Rural Health Clinics are paid an encounter rate based on the clinic’s cost per patient.
The cost per patient is based on:
Allowable Clinic Expenses
Total Patient Encounters
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RHC Encounter Rate 2012
The current maximum RHC encounter rate is $78.54. This represents a .6% increase over 2011.
The rate increases annually using a formula based on the MEI.
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RHC Productivity Standards
Physician – 1 FTE MLP – 1 FTE
4200 Encounters 2100 Encounters
19 per day 9.5 per day
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Medicare Part A: RHC Claims
Rural Health Clinic claims are administered by Medicare Part A.
It is a Part B (Physician Service) benefit, using the structure of Medicare Part A.
This is why we deal with UB04, Cost Reports, Revenue Codes, etc.
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Fee Schedule – 1500 Claims
In Missouri – some Medicare and Medicaid claims will continue to be submitted and paid via the Physician Fee Schedule on a 1500, including:
All lab services
Technical Components for all Dx testing
Hospital Professional Services
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Medicare RHC Payments
Medicare will pay 80% of the RHC encounter rate.
The patient will be responsible for 20% co-insurance and deductible amounts, which are based on total charges instead of an allowable.
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Medicaid RHC Payments
Missouri Medicaid sets the RHC via cost report.
Independent RHC encounter rates are based on the CMS cap.
Provider-based RHCs are set based on the reasonable cost to charge ratio and Medicare.
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RHC Location Requirements
RHCs must be located in one of the following:
Geographic-based Health Professional Shortage Area (HPSA)
Population-based HPSA
Medically Underserved Areas (MUAs)
Governor Designated and Secretary certified area
The shortage area designation must have been updated within the past four years.
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RHC Location Requirements
The clinic must also be located in a non-urban area according to the U.S. Census Bureau.
RAC ‘Am I Rural’ lookup tool:
http://maps.rupri.org/circ/racrural/amirural.asp
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Physical Facility1
The Rural Health Clinic program does not place any restrictions on the type of facility that can be designated as an RHC. A Rural Health Clinic may be either a permanent location that is a stand alone building or a designated space within a larger facility. The clinic can also be a mobile facility that moves from one community to another community.
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RHC Physician Staffing Requirements The clinic must have a designated medical director.
A physician must be present in the clinic once every two weeks.
The physician/medical director must see at least one patient and provide medical direction, consultation, and oversight.
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RHC Mid-Level Provider (MLP) Requirements A nurse practitioner, physician assistant, or certified nurse mid-wife must be employed by the RHC.
The MLP must be available for patient at least 50% of posted patient hours.
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RHC Approved Providers
Physicians – M.D. or D.O.
Mid-level providers – N.P., P.A., or C.N.M.
Mental Health Providers:
Clinical Psychologist – Ph.D.
Licensed Clinical Social Worker
(NO L.P.C. or C.P.C!)
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Lab Services
Each RHC must have the ability to perform:
Chemical examinations of urine
Hemoglobin or Hematocrit
Blood Sugar
Occult Blood
Pregnancy test
Primary culturing for transmittal to lab
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Emergency Response
Rural Health Clinics must be able to provide “first response” services to common life-threatening injuries and acute illnesses. In addition, the clinic must have access to those drugs used commonly in life-saving procedures.
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RHC Policy and Procedure Manual1
The Clinic must also maintain written patient care policies that:
Are developed by a physician, physician assistant or nurse practitioner, and one health practitioner who is not a member of the clinic staff.
Describe the services provided directly by the clinic's staff or through arrangement.
Provide guidelines for medical management of health problems.
Provide for annual review of the policies.
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RHC Service Locations
Rural Health Clinic services can be provided at:
the clinic (or center)
a nursing home (SNF beds included)
the patient’s place of residence
elsewhere (i.e. the scene of an accident)
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Rural Health Clinic Services - Medicare
Physicians' services
Services and supplies incident to a physician’s service
Services of nurse practitioners (NP), physician assistants (PA), and certified nurse midwives (CNM)
Services and supplies incident to the services of nurse practitioners and physician assistants (including services furnished by nurse midwives)
(Medicare Benefit Policy Manual Chapter 13)
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Rural Health Services (Continued)
Visiting nurse (VN) services to the homebound
Clinical psychologist (CP) and clinical social worker services (CSW)
Services of registered dietitians or nutritional professionals for diabetes training services and medical nutrition therapy
Otherwise covered drugs that are furnished by, and incident to, services of physicians and non-physician practitioners of the RHC/FQHC
(Medicare Benefit Policy Manual Chapter 13)
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Non-Payable but Covered Services
These services are bundled and are not separately payable as encounters:
Nursing Visit
Telephone Consultation
Diabetic Nutrition Counseling
Zostavax (can be billed to Part D)
Hepatitis
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CMS Quick Reference Guide
See the following chart for a quick reference on RHC billing.
This is also posted on www.northamericanhms.com.
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNProducts/downloads//RuralChart.pdf
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Medicare Advantage
There are two types of Medicare Advantage Plans:
1. Private Fee For Service – no contract necessary. Send RHC rate letter. Submit claims on UB04. Should pay the RHC encounter rate.
2. Regional PPO – must negotiate RHC payment in contract. Not required to pay rate.
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References
1. Starting a Rural Health Clinic - A How-To Manual. US Dept of Health and Human Services. Health Resources and Services Administration. Page 2
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CMS and Medicare Resources
CMS Rural Health Center – www.cms.gov/center/rural.asp
Online Manuals - www.cms.gov/Manuals/IOM/list.asp?listpage=1
Trailblazer’s Rural Health Clinic Manual www.trailblazerhealth.com/Publications/Training%20Manual/rhcmanual.pdf
Cahaba – www.cahabagba.com
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Rural Health Resources
National Association of RHCs (NARHC)
www.narhc.org
Rural Assistance Center
http://www.raconline.org/topics/clinics/rhc.php
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Preventive Service Links
IPPE (MM6445) http://www.cms.gov/MLNMattersArticles/downloads/MM6445.pdf
Annual Wellness Exam (MM7079) https://www4.cms.gov/MLNMattersArticles/downloads/MM7079.pdf
MPS Chart: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//MPS_QuickReferenceChart_1.pdf
CMS Preventive Services Center: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html
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Medicare Preventive Reference
MPS Chart: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//MPS_QuickReferenceChart_1.pdf
CMS Preventive Services Center: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/PreventiveServices.html
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More CMS Resources
Medicare Claims Processing Manual – UB04 Completion www.cms.gov/manuals/downloads/clm104c25.pdf
Medicare Claims Processing Manual – Chapter 9 RHC/FQHC Coverage Issues
www.cms.gov/manuals/downloads/clm104c09.pdf
MedLearn Catalog www.cms.gov/MLNProducts/downloads/MLNCatalog.pdf
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Contact Information
Charles A. James, Jr.
North American Healthcare Management Services
President and CEO
888.968.0076
www.northamericanhms.com
www.northamericanhms.com 888.968.0076